The impact of a large scale treatment program on HIV treatment delivery in a resource limited setting: a case study of urban treatment in Johannesburg, South Africa

A thesis submitted to the Faculty of Health Sciences, University of Witwatersrand, in fulfillment of the requirements for the degree of Doctor of Philosophy Johannesburg, 2016Introduction This thesis investigates the impact of a large-scale HIV treatment program on the outcomes and costs associated with HIV treatment delivery, using urban South Africa as a case study. In order to investigate HIV treatment delivery it is broken down into two major components; 1) the chronic outpatient treatment of HIV and 2) the acute inpatient treatment of HIV related conditions. Outpatient HIV treatment Through task shifting the South African outpatient HIV treatment program evolved over time to scale up in an environment of limited resources. There is no economic evaluation of task shifting in a routine environment in South Africa. Papers 1 and 2 focus on understanding the outcomes, costs, and cost effectiveness of partial and full task shifting. The results of this work provided evidence to support the shift to nurse initiation and management of antiretroviral treatment (NIMART). It also highlighted the fact that within the NIMART program there may be a need to triage patients between primary health clinics and hospital based outpatient clinics to better utilize scarce resources. Inpatient HIV treatment Prior to antiretroviral treatment (ART) inpatient care of acute HIV related conditions was common, but with the rollout of antiretrovirals in 2004 it was anticipated that this would reduce. Since 2004 there has been no economic evaluation, which speaks specifically to the shifting HIV burden on inpatient facilities. Papers 3 and 4 focus on understanding the HIV burden on inpatient facilities by examining the outcomes (mortality) and costs associated with HIV positive admissions. The results show that almost half (45%) of inpatient medical admissions were confirmed HIV positive, not on ART and accounted for the majority of the costs. In addition to that, the majority of medical inpatients (58%) who died were HIV positive, which lends support to other evidence that suggests that national HIV mortality is seriously under reported in South Africa. Conclusion Large-scale ART continues to move outpatient HIV treatment further along the task-shifting continuum, while maintaining outcomes with some potential reductions in cost. However, large-scale ART has not had the expected impact of substantially reducing the HIV burden on inpatient facilities.MT201